2013 FNCCConference Participant’s Application for Mid-Atlantic & South Zone

(Send this half of sheet in with payment and keep the bottom half for your records)

(Important: FNCC Conferences are from Friday – Monday. Participants are expected to attend all four days.)

Name of FNCC Conference: ______Conference Dates: ______

First Time FNCC Yes _____ No (how many times) ____ / LANGUAGE (for language conf): ______
First Name: ______ / Division: MD ___ WD ___ YMD ___ YWD ___ ESD ___
Last Name: ______ / Leadership Position: ______
Address:______
______ / Diet Restrictions: ______
City: ______State: ____ Zip ______ / Vegetarian: Yes ____ No ____
Vegan: Yes ____ No ____
Email: ______ / Roommate Request: (Zone/Area if not Carolina/VA/WDC)
______
Home Phone: ______ / Transport: Car ___ Plane ____ Bus/Train ____
Work Phone: ______ / Emergency Contact Information:
Cell Phone: ______
Age (Required) ______Male: ____ Female: ____ / Name: ______
Relationship: ______
Health: Excellent ____ Good ____ Fair ____ / Phone: ______
Do you take medication? Yes ____ No ____ / Cell: ______
If “Yes”, for what condition(s)?
______
Please list any health conditions that the FNCC staff should be aware of
so they can prepare for your stay or assist you in an emergency situation. / Region: ______Area ______
Chapter: ______District: ______
______
(Note: knowing your health condition(s) helps us better serve your needs. There are a limited amount of “handicapped” rooms, so please indicate if required. Also indicate if a wheel chair is needed and if person is wheel chair bound) / If under 18, Minor Consent form included: Yes ____ No ___
Applicant’s Signature: ______
Today’s Date: ______

………………………………………………………………………………………………………………………………………………………………………

(Tear on the dotted line and return the top half of application to the SGI-USA Washington D.C. Office with your payment.)

Instructions: (Please read, sign above and keep this half of the application with you.)

1)Accurate and complete information on this application is very important.

2)Mail completed application with $495payment by check, money order or credit card to the SGI-USA Washington DC office, care of "FNCC Conference." All checks made payable to “SGI-USA.”($248 per child under 13 at Family Conf.) If you are using Master/ Visa credit or check card for your payment, you may fax your application and signed credit card payment formto the DC office (202-338-5496).

NOTE:CREDIT CARDS AND CHECKS WILL BE PROCESSED UPON CONFIRMATION OF SEAT AVAILABILITY.

3) DO NOT MAKE TRAVEL RESERVATIONSuntil you have received confirmation of a seat for your conference.

Plane arrival after 6 pm will incur additional transportation charges.

$57.50 from Ft. Lauderdale Airport and $91.25 from Miami Airport. (2010 prices)

4)Travel arrangements must be reported to the Washington DC office atleast three weeks prior to the day of the FNCC conference you are attending (please use the Travel Information Form or e-mail directly to ). Call the Washington DC office if you need assistance with travel to FNCC. See below for telephone numbers.

5) A fee of $50 is charged for any cancellation by the applicant placed less than seven (7) days prior to the scheduled conference. Should FNCC cancel the scheduled conference, SGI-USA will reimburse any penalties charged to the applicant from travel cancellations and the $495 conference payment will be immediately returned. Applicant must provide proof of travel arrangements in order to receive penalty compensation.

6) Applicants under the age of 18 years must have a “Parent Consent & Release of Liability” form completed and signed and a copy to be taken to FNCC by the minor as proof. If you have any other questions, please contact the SGI-USA Washington DC Community Center and speak to the FNCC Zone office staff.

Payment and Application Mailing Address

SGI-USA Washington D.C. Culture Center Today's Date: ______

3417 Massachusetts Ave NW Attn: FNCC

Washington, DC 20007My Check

202-338-5491 Toll-Free @ (877)744-9321 Paid with Credit Card Yes __ No __

FAX: (202) 338-5496Amount Paid: ______

FNCC Conference Location

SGI-USA Florida Nature & Culture Center Conference Dates: ______

20000 S.W. 36th St. Weston, FL 33332-1929 (954) 349-5000 or Toll-Free @ (866) 677-5100 (Rev.12-13-12)